Healthcare Associated Infection Reporting Template (HAIRT) Section 1 – Board Wide Issues

Key Healthcare Associated Infection Headlines for March 2011 December 2010 saw the lowest number of cases of Clostridium difficile infection

(CDI )and Meticillin Senistive Staphylococcus aureus (MSSA) bacteraemia in NHS Grampian since 2009. A relatively low rate of CDI cases was maintained in January but the rate MSSA cases rose to approximately average in this month.

There was one case of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia in December 2010 and one in January 2011

Numbers of cases of CDI have fallen for 3 consecutive months in Aberdeen Royal Infirmary

There were no cases of MRSA bacteraemia in Aberdeen Royal Infirmary for 3 consecutive months from November 2010

There were no cases of Staphylococcus aureus bacteraemia (MRSA or MSSA) or Clostridium difficile in Dr Gray’s Hospital for 3 consecutive months from November 2010.

There were no cases of Staphylococcus aureus bacteraemia (MRSA or MSSA) in Woodend Hospital in December 2010 or January 2011.

Rates of CDI have been consistently low in Community Hospitals since September 2010.

There were no cases of MSSA or MRSA bacteraemia in December 2010 and January 2011 in Community Hospitals.

December 2010 saw the lowest rates of out of hospital CDI and MSSA bacteraemia for 12 months but case numbers rose once again in January 2011.

Staphylococcus aureus (including MRSA)

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This section of the HAIRT covers Board wide infection prevention and control activity and actions. For reports on individual hospitals, please refer to the ‘Healthcare Associated Infection Report Cards’ in Section 2.

A report card summarising Board wide statistics can be found at the end of section 1

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at:

Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252

NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

Current HEAT Status

No new data from HPS.

SAB 90 Day Rapid Improvement Programme

In February the Chief Nursing Officer invited NHS QIS to lead ongoing national support activity around SABs, with the support of HPS and NHS Education for Scotland (NES), to ensure that opportunities to maximise local improvement continue to be identified and acted upon. Using the data and experience gathered from NHS Grampian, NHS QIS along with these national stakeholder partners will continue to support us on the development of tailored improvement activities that will:-

be informed by local data and assessment undertaken to date; identify suitable improvement interventions that aim to reduce overall SAB numbers; and define a measurement plan to track their impact.

This has been translated into a 90 day rapid improvement programme. The first 30 days involve planning which clinical teams we are going to work with and on which interventions, the second 30 days being about testing, evaluating and amending those interventions and the final 30 days involving consolidation of them.

For the most part the interventions build on work that has been ongoing since the summer of last year and include device insertion checklists and care bundles and the introduction of blood culture packs. New interventions identified by clinical teams include the training of junior doctors around line care and the introduction of chlorhexidine washes. We are also required to test a new national combined opportunity and technique hand hygiene monitoring tool.

An update on progress will be contained within the next report.

MRSA Screening

Following publication of the MRSA Screening Programme reports on 23 February, the MRSA National Programme Board has recommended that minimum screening practice across NHSScotland should take the form of a 3 question Clinical Risk Assessment that is applied to patients on admission or pre-admission. Those with one or more positive answers to the 3 questions asked will proceed to swab based screening.

In addition, all patients in 5 high impact specialties (renal, cardiothoracic, vascular, intensive care and orthopaedics) should be screened as a matter of course using swabs.

The MRSA National Programme Board recommendations were endorsed by the HAI Taskforce and the Cabinet Secretary for Health & Well Being has accepted them in full.

Health Protection Scotland have been tasked with developing an operating protocol along with key performance indicators. This will set out what is required of NHS Boards to meet the revised minimum MRSA Screening policy requirement.

All NHS Boards will be asked to ensure local delivery against the operating protocol by end March 2012.

Discussion is currently taking place with service leads about how this is achieved through existing programmes such as Leading Better Care and this planning process is to be completed no later than end May 2011.

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Transitional funding for 2011/12 will be provided. For NHS Grampian, as a Pathfinder Board, this will be based on spend levels to support MRSA screening activity in 2009/10. This will ensure continued support for NHS Board MRSA Screening Project Manager (PM) and additional posts during the 2011/12 transitional year. It is anticipated that local implementation plans will be developed by the PM in partnership with the NHS Board Nurse Director.

Finally, the cost modelling that has been undertaken by SGHD and HPS confirms that the revised minimum policy approach of CRA, plus swabbing of patients being treated in high impact specialties, will come at a significantly reduced cost when compared to universal screening using a single nasal swab; and will provide similar detection rates of true MRSA colonisation.

Clostridium difficile

Current HEAT Status

No new data from HPS but NHS Grampian is still on track to meet this target.

Hand Hygiene

The NHS Hand Hygiene Campaign 11th Bi-monthly Audit Report which was published in January confirmed that NHS Grampian achieved a compliance figure of 98%, the highest since the Campaign began and the second highest Board score for that reporting period.

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Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at:

http://www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx

NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of section 1 and for each hospital in section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at:

http://www.washyourhandsofthem.com/

NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national hand hygiene monitoring can be found at:

http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

Cleaning and the Healthcare Environment

Cleaning

Local data collection shows that the results for December and January at Woodend Hospital have not improved significantly. As noted in previous reports, external verification of audit results were to be sought as it was thought there may be inconsistency of monitoring. The issue of domestic staff being pulled away from cleaning for patient related duties appears to be most acutely felt at Woodend Hospital. Discussions are ongoing to resolve these issues.

Antimicrobial Prescribing

Acute Care

The following graph shows ‘4C’ prescribing as a percentage of total antibiotic packs vs number of cases of CDI (in ARI, Dr Gray’s Hospital, Woodend Hospital). The trend in overall antibiotic usage continues to be static, as does the number of CDI cases for the same time period.

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Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of section 1 and for each hospital in section 2. Information on national cleanliness compliance monitoring can be found at:

http://www.hfs.scot.nhs.uk/online-services/publications/hai/

Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at:

http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

Aberdeen Royal Infirmary/Dr Grays Hospital/Woodend Hospital - 4Cs as a % of all Antibiotics and the Number of CDI Cases - March 2008-December 2010

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Clostridium difficile rates from Jan 10 onwards use a new definition for Clostridium difficile infection, following advice from HPS.

Community Hospitals

The following graph shows the same data for Community Hospitals in NHS Grampian. The reduction is not as dramatic due to clinicians there using both primary and acute care prescribing guidelines but a considerable decrease is still seen in their use and a slightly delayed drop in the number of cases of CDI.

The following 2 graphs show prescribing data for each of the high risk antibiotics in acute hospitals and primary care (including community hospitals). Sustained reductions in prescribing can be seen across NHS Grampian.

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Community Hospitals - 4Cs as a % of all Antibiotics and the Number of CDI Cases - March 2008-December 2010

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Clostridium difficile rates from Jan 10 onwards use a new definition for Clostridium difficile infection, following advice from HPS.

Aberdeen Royal Infirmary/Dr Grays Hospital/Woodend Hospital - 4Cs (DDDs per 1000 Bed Days) - March 2008-December 2010

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NHS Grampian Primary Care

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Healthcare Associated Infection Reporting Template (HAIRT)Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ that provide information, for each acute hospital [and key community hospitals – delete if appropriate] in the Board, on the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections, as well as hand hygiene and cleaning compliance. In addition, there is a single report card which covers all community hospitals [which do not have individual cards], and a report which covers infections identified as having been contracted from outwith hospital. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up to date information on HAI activities at local level than is possible to provide through the national statistics.

Understanding the Report Cards – Infection Case NumbersClostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data are presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website:

Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=2139&sectionID=1

Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252&sectionID=1

For each hospital the total number of cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out of hospital” report card.

Understanding the Report Cards – Hand Hygiene ComplianceGood hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website:http://www.washyourhandsofthem.com/Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital report card presents the percentage of hand hygiene compliance for all staff in both graph and table form.

Understanding the Report Cards – Cleaning Compliance

Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website:http://www.hfs.scot.nhs.uk/online-services/publications/hai/The first page of each hospital Report Card gives the hospitals cleaning compliance percentage in both graph and table form.

Understanding the Report Cards – ‘Out of Hospital Infections’Clostridium difficile infections and Staphylococcus aureus (including MRSA) bacteraemia cases are all associated with being treated in hospitals. However, this is not the only place a patient may contract an infection. This total will also include infection from community sources such as GP surgeries and care homes and. The final Report Card report in this section covers ‘Out of Hospital Infections’ and reports on SAB and CDI cases reported to a Health Board which are not attributable to a hospital. Given the complex variety of sources for these infections it is not possible to break this data down in any more detail.

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